SPECIFIC NASAL INFECTIONS 41

that nasal lupus and lupus of the face have a common origin in the nasal
vestibule at the mucocutaneous junction (Plate II, 1). The septum is the part
generally affected where the characteristic nodular infiltration is found leading
in some cases to ulceration and loss of tissue. External deformity may be met
with, such as sinking in of the tip of the nose, while the alae nasi and the
mobile part of the septal cartilage may be eroded and finally destroyed.

DIAGNOSIS. The diagnosis is not difficult as a rule. The slow progress of the
disease distinguishes it from syphilis while the characteristic nodules, called
apple-jelly nodules, and in many cases the coexisting skin lesion will differenti-
ate it from tuberculosis.

TREATMENT. Isoniazid is the drug of choice in the treatment of lupus
vulgaris, either alone or combined with streptomycin and PAS. In some cases
a response may be obtained from vitamin D2 (calciferol) given in the form of
high potency ostelin in a dose of 100 000-150 000 units daily, depending on
body weight. The danger of high doses are hypercalcaemia and renal damage.,
so that regular checks must be made, especially if there is evidence of
dehydration.

SARCOIDOSIS

Sarcoidosis resembles lupus in the formation of nodules in the mucosa of the
nasal vestibule, but the disease may affect the nasal bones which show
characteristic cystic lesions on radiography. The aetiology of sarcoidosis is
unknown. Diagnosis is made from histological examination of the nodules,
and it is treated by steroid therapy supplemented by vitamin D.

MALIGNANT GRANULOMA

This is a progressive destructive ulceration of the nose and often the nasal
cavities and sinuses. It is chronic inflammatory in nature but is potentially
malignant and may become a lymphoma. There are two main types described.
Stewart's type consists of an indurated swelling of the nose, nasal vestibule and
septum leading to a progressive ulceration of cartilage and bone. Microscopy
shows a dense accumulation of cells, mainly lymphocytes. The second type is
Wegener's which takes the form of a necrotizing giant-cell granuloma
beginning in jthe nose but showing confluent necrotic lesions in the lungs and a
granulomatous involvement of the kidneys, resulting in renal failure which
often proves fatal. Microscopically the presence of multinucleated giant cells
in necrotizing granulation tissue, often grouped around blood vessels showing
periarteritis and sometimes thrombosis, is diagnostic. The disease is more
common in males, and has to be distinguished from syphilis, tuberculosis and
malignant disease as well as from certain tropical diseases, such as yaws,
gangosa, leprosy and oriental sore.

TREATMENT. Treatment of Stewart's type is by low-dosage irradiation,
which often gives good results. Wegener's type, which causes much more
constitutional upset, is now treated by azathioprine (Imuran) tablets, 50 mg
twice daily and increasing to 200 mg in the day. This is combined with
prednisolone in doses of 10 mg thrice daily. The outlook in Wegener's type,
which formerly was very poor, is now improved.